Hospital Care For The Indigent Rule 1: Fill & Download for Free

Patient dumping is a regular practice (at least at the hospital where I worked for 25+ years), but hospitals are generally careful to dump patients who are unable to advocate for themselves such as illegal immigrants, non-English-speakers, and very ill patients without friends or family present to advocate for them. This is a cynical method of avoiding publicity, leading laypersons to believe dumping is rare, when in reality, it’s a regular occurrence.This post on patient dumping got me trespassed (kicked off campus for 3 years) by the University of Florida, despite the fact that I hadn’t been on campus since being forced to quit my job over a year prior (except for a few medical appointments). Yes, the University of Florida Police Department officers actually came to my off-campus house to issue me the trespass notice.My “inflammatory” post:UF Health Shands Hospital was front-page news all over the country 35 years ago, when they loaded an AIDS patient from South Florida onto a plane, stuffed $300 in his pockets, and flew him to San Francisco, where he was dumped at the office of the city's AIDS Foundation. UF Health Shands Hospital learned its lesson, right? Nope. UF Health Shands just learned how to dump patients "under the radar" so that media outlets don't recognize what is happening.What is patient dumping? EMTALA (Emergency Medical Treatment and Active Labor Act) is a law that governs when a patient may be 1.) refused treatment in an emergency room; and 2.) transferred from one hospital to another. A patient who presents to the Emergency Department with an emergency medical condition must be seen and stabilized before being transferred to another facility or discharged home (this includes active labor with contractions). Originally, EMTALA was considered to apply to Emergency Department care only, but recent court decisions indicate that EMTALA may also apply to patients who have already been admitted to the hospital in Inpatient status and are being discharged home or to a facility. See https://www.mcguirewoods.com/Client-Resources/Alerts/2012/9/Hospitals-Take-Note-EMTALA.aspxEMTALA enforcement is triggered by complaints, so UF Health Shands has learned not to inappropriately transfer patients to other hospitals as this will almost invariably result in a complaint from the receiving hospital. Instead, UF Health Shands inappropriately discharges patients to rehab/skilled nursing facilities or to home before the patient's emergency medical condition has been stabilized.Example: After working for about a year as an Orthopaedic/Orthopaedic Trauma Case Manager/Discharge Planner, I transferred to the Admission Discharge Transition Unit to work as a staff nurse. One day we had a Trauma patient (brain injury) transfer to the ADTU for discharge teaching prior to discharge home. In the process of admitting the patient to the ADTU, helping him to the bathroom, and having our telephone translation service help translate the patient's discharge instructions to him, I discovered that not only could the patient not walk without assistance, he was disoriented to the degree that he didn't know where he was (didn't know he was in the hospital, didn't know he was in Gainesville Florida, didn't know the month, day, or year, and only knew his name and that "I got hurt").He lived in the Lake City/Live Oak area about 50 miles away, and his instructions were to catch a bus outside the hospital, take it to the Greyhound station where he would purchase a ticket to Live Oak using the voucher the Discharge Planner had given him, and then take a city bus home from the station.I quickly realized that, with his inability to walk unaided, lack of English language skills, and confusion, these instructions were beyond his capabilities. Having worked as a Case Manager/Discharge Planner for Orthopaedic Trauma in the immediate past, I knew I needed to call the patient's Discharge Planner and ask her to revise the plans in a way that would allow this man to get home safely.I assumed the Discharge Planner had not been informed of the patient's confusion, his inability to walk without assistance, and lack of English language skills. As requested, the Discharge Planner did adjust the discharge plans to my satisfaction, but I still wondered (silently) why a patient with such a severe head injury was not being sent to a rehab facility. However, some patients don't want to go to Rehab, and that is their right.The next day, my manager informed me that "The Trauma Docs were very unhappy that you questioned the discharge plan," and "the Trauma Doctors were satisfied with the discharge plan and were not happy that you interfered," and "the Trauma Doctors said they will not use the ADTU for their discharges if the staff continues to question the plans made by the Trauma Service Discharge Planners." I was truly flabbergasted that the Trauma Service endorsed an unsafe discharge plan.It wasn't until years later, when I was harassed to the point I believed my life was in danger at my job in the Case Management/Patient and Family Resources Department (to which I returned after a couple of years in the ADTU), that I realized the Trauma service was dumping their patient and was unhappy that I interfered with the dumping process.For anyone who hasn't read my previous posts, I reported a Pediatric Social Worker, to our mutual supervisor, the Director of Patient and Family Resources, for reading a child's medical chart for the sole purpose of gossiping about the child's obesity. It turned out that the social workers father is a mafioso, and he and his daughter initiated the harassment protocol (also called "The White Glove Treatment" and "Fair Game" depending on the satanic cult that initiates it), with the assistance of my Director of Patient and Family Resources,who coordinated the employment aspect of my massive, ongoing, covert, violent harassment which included receiving the head of a cat in the mail, the killing/dismemberment of at least 6 cats in the feral colony I care for, having "air freshener" to which I was highly allergic sprayed repeatedly in my workspace, multiple break-ins to my condo, a nail in my tire, etc., etc.Due to UF Health Shands' apparent ties with organized crime, I can't help but wonder what way they profit (in addition to some of the Board of Directors compensation packages in excess of a million dollars a year) when they dump patients. I do know that UF Health Shands is dinged financially when they keep patients longer than Medicare-recommended DRG (Diagnostic Related Groups) guidelines. However, UF Health Shands receives money from the Florida Legislature that's supposed to fund both indigent hospital care *and* post-hospital rehab. The "whys" need to be investigated by somebody with more insider financial knowledge than me.What can family members do to prevent their loved ones from being dumped? There are some ways in which family members can help decrease the possibility of dumping. One way, of course, is to be an active, present advocate for your loved one while he/she is hospitalized. Hospitals are much more likely to dump someone without an advocate (like the AIDS patient referred to at the beginning of this post).You should know that to financially qualify for post-hospital rehab per Medicare guidelines, the hospital patient must be an Inpatient for a minimum of 3 days *and* have a need for skilled nursing care. These are Medicare rules.Many patients are admitted under Observation or Ambulatory status (especially on weekends) so it's very important for family members to find out what status the patient has been admitted under (Ambulatory, Observation, or Inpatient) and ensure that Case Management immediately switches the patient to Inpatient status if appropriate. It cannot be done retroactively, so family members should address this immediately.If the patient is too ill/unstable to be cared for at home post discharge from an acute care hospital such as UF Health Shands, family members should let Case Management know ASAP if they will not be able to care for the discharged patient at home. Finally, there are options for more intensive care than is normally provided by skilled nursing facilities. Ask if your loved one will qualify for Select Hospital or Shands Rehab Hospital; these facilities provide more intensive nursing care than a skilled nursing facility (in the case of Select Hospital) and more intensive rehab services (Speech, Occupational, and Physical Therapy Services, in addition to Recreation Therapy and Psychology) in the case of Shands Rehab facility.Finally, complaints can be made to the agencies responsible for enforcing EMTALA: Centers for Medicare and Medicaid Services (CMS) or the State Survey Agency (the Consumer Complaint, Publication, and Information Call Center of the Florida Agency For Healthcare Administration in this state : http://ahca.myflorida.com/Contact/call_center.shtml). While I would consider these complaints last-resort, it's very important that they be informed of cases of patient dumping in order to note trends among particular hospitals. You may need to be quite assertive to insist your concerns are addressed.Addendum: Since this post was written, there have been reports of "churning" by UF Health Shands Hospital and other hospitals. "Churning" is a method of ensuring that a patient's Medicare can continually be charged for new DRGs. The method is this: the acute care hospital (such as UF Health Shands) discharges a patient to a long-term acute care hospital (such as Select Hospital), often before the patient is well enough to leave ("dumping"). New DRGs can be billed in the new care setting (by the way, UF Health Shands is a partial owner of Select Hospital).The patient gets sicker at the acute long-term care hospital or skilled nursing facility (perhaps because he/she was discharged from the acute hospital too soon), and gets sent back to the acute hospital. The acute hospital is now able to bill for *new* DRGs. Once the new DRGs have run out at the acute-care hospital (Shands), the patient is transferred back to the acute long-term care hospital (Select) or skilled nursing facility again, and the facility can also charge for *new* Medicare DRGs. This "churning" between facilities results in the patient getting sicker and sicker, while new DRGs can be billed with each transfer.A healthcare professional commenting on "churning" on a web-based newsmagazine for healthcare professionals and hospital administrators) stated that once her father had been "churned" multiple times, and he was actually killed when he was no longer profitable (please note, this healthcare professional was referring to a facility on the West Coast, not to UF Health Shands. However, I have also read a report on Facebook of patient "churning" occurring at UF Health Shands Hospital, with the daughter complaining of sadistic care and hospital-induced infection which caused her father's death).Note: This post is in no way meant to provide legal advice. Writer Kathleen Maynard, RN, OTR/L is a nationally certified Case Manager (ACM-RN). For further information on patient dumping, see references noted in body of post, and https://www.healthlawyers.org/hlresources/Health%20Law%20Wiki/Emergency%20Medical%20and%20Labor%20Treatment%20Act%20(EMTALA).aspx

Hospitals don't know if they'll be paid at all when dealing with an unconscious/emergent patient. While that's the case, there are a few ways this can play out...The Emergency Medical Treatment and Active Labor Act (EMTALA) essentially requires hospitals to provide emergency medical treatment to anyone in need. A hospital must behave in the same manner whether or not they expect to collect on the patient's care.More on the EMTALA (including the following excerpts) can be found here: http://en.wikipedia.org/wiki/Emergency_Medical_Treatment_and_Active_Labor_Act"The EMTALA is a U.S. Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. Participating hospitals may only transfer or discharge patients needing emergency treatment under their own informed consent, after stabilization, or when their condition requires transfer to a hospital better equipped to administer the treatment.""EMTALA applies to "participating hospitals." The statute defines "participating hospitals" as those that accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program. However, in practical terms, EMTALA applies to virtually all hospitals in the U.S., with the exception of the Shriners Hospitals for Children, Indian Health Service hospitals, and Veterans Affairs hospitals."Hospitals don't know if they'll even receive $1 in this scenario. The financial responsibility pertaining to the medical treatment performed is ultimately the patient's. As a 'customer' receiving care, you are essentially entering into a contract with the hospital whether you're awake to consent to the care or not. Legal proceedings may establish another party's liability in respect to these bills, however the bill stays in the patient's name.Even if a 3rd party is directly responsible for someone's hospitalization, there is no direct relationship between that 3rd party and the hospital, so the hospital must attempt to collect from the patient for services rendered. When the bills get extensive, a hospital will typically file a lien against any insurance policy settlement 'payout' that may arise from the situation to protect their financial interests. There's no promise they'll see a penny, but they try to make sure you can't simply walk away from the situation with a check should one come your way.In the event that medical care results in large outstanding balances that will clearly never be recovered, or after reasonable efforts to collect have been exhausted, hospitals can write-off these expenses as a loss for tax purposes, as 'charitable services'. This is a fairly common practice with these situations considering how often our typically-massive medical bills can't be paid off, even after whatever legal wrangling that can be done is done.People are often under the false impression that some sort of "indigent patient insurance" covers these situations. There may be some relief in certain situations in certain states that I can't personally rule out, but I'm writing this answer based on several examples I've seen in California, which together span about 20 years, and in which the mythical "indigent patient insurance" never came up. By the time each situation was put to rest, this lien/charity/write-off route had been taken every single time a significant bill was involved.Nobody's in the business of simply paying-off other peoples' bills at face-value... The expense of the claims, the expense of the coverage, etc... it's a lose/lose exercise in futility for both parties. But a $1,000,000 unpaid bill that can be put against taxes at the end of the year? Hospitals can put that to good use. Let's say it had been an insured patient instead, whose insurance had paid 40% of the otherwise 'uninsured's' bill... In the end, that's fairly similar to writing-off the same bill, financially.This is everyday stuff in the medical world. It's planned for, it's expected, it's a certainty... It's going to happen, and it's going to happen over and over, at that. While they'd certainly prefer full cash payment, you can rest assured that hospital managers and directors aren't "rolling the dice" on their hospital's future over these scenarios. When you're wheeled into the ER, you're going to go straight into whatever insanely expensive treatment may be needed to keep you alive whether you can pay for it or not, they'll worry about the numbers later.

In My Opinion San Francisco declared a state of emergency over the coronavirus for the following reasons:The City and State of California were BROKE before the crisis and want Federal Tax Dollars to pay their bills after decades of fiscal mismanagement.The “Indigent Health Care” system depended on Hospital Emergency Rooms and is in a state of near-collapse from decades of overuse by people unable to pay their bills who eschew free standing clinics and use Hospital Emergency rooms as their Primary Health Care Provider.Decades of overspending on Indigent Health Care prevented the State from building and maintaining a stockpile of strategic healthcare materials such as Personal Protective Equipment, hard goods like Ventilators or maintain reserve capacity in Hospital wards/beds sufficient to provide room for the Patient surge of an epidemic.Their “Emergency Housing” system is IN collapse and forced large numbers of people to live in “Homeless Encampments”in parks, riverbeds, vacant lots etc in the worst possible conditions for transmission of the disease.Their Police Depts are hamstrung by “Do Not Arrest” rules and unable to maintain basic Civil Order without the National Guard being activated (and paid for with Federal Tax Dollars)See #1